Wednesday, October 9, 2013

Worthwhile Canadian initative: health care edition

I’ve been blogging a lot recently about the various ins and outs of
theAffordable Care Act and it is
implementation. (See here, here, and here for example) However, let’s keep our
eyes on the ultimate prize:

That’s an Ontario Health Insurance Plan ID card -- the provincial manifestation of Canada's universal Medicare system. One of my Canadian
friends showed me hers about six years ago when we were working on a
health-care proposal to show university administrators during labor
negotiations. That simple card, she
explained to me, guaranteed her access to any clinic or hospital in Ontario. We
looked at the magical talisman sitting on the table for a moment, sighed and
got back to work.

With that tantalizing thought in mind, let’s compare current user experiences
between an American and a Canadian.Just
to make things interesting, we’ll assume the American has decent health
insurance. Follow me below the fold for a comparative experience in health
care.

Scenario #1: routine visit for medical condition

The American schedules an appointment with their doctor’s office, shows
their insurance card, sees the doctor. She then visits the desk, pays the
applicable co-pay (usually anywhere from $15 to $30) and leaves.

The Canadian schedules and appointment with their clinic or doctor’s
office.She shows her OHIP card, see the
doctor and leaves.

Scenario #2: A semi-urgent medical issue comes up while our protagonist is
away on business in state/province

The Canadian schedules an appointment with the nearest clinic or doctor’s
office. She shows her OHIP card, sees the doctor and leave.

The American has to find the nearest doctor’s office in network, which
might not be the nearest one. If there is not a nearby doctor’s office
in-network, she has to get pre-approval from her insurance company for an
out-of-network visit. The co-pays will generally be higher if the visit is
approved and the patient might be on the hook for additional costs even if the
visit is approved.

Scenario #3: A semi-urgent medical issue comes up while our protagonist is
away on business out of her home state/province

The Canadian schedules and appointment with the nearest clinic or doctor’s
office. She shows her OHIP card, sees the doctor and leaves. Manitoba’s health bureaucrats
bill Ontario’s health bureaucrats according to an existing interprovincial agreement.

The American has to find the nearest doctor’s office in network, which
might not be the nearest one. If there is not a nearby doctor’s office
in-network, she has to get preapproval from her insurance company for an
out-of-network visit. The co-pays will generally be higher if the visit is
approved and the patient might be on the hook for additional costs even if the
visit is approved. Note that it is much less likely that an out-of-state
provider will not be in-network, increasing the degree of difficulty for our
hypothetical American. She sees the doctor and leaves.Costs and paperwork will follow if things go
well. A multi-month fight with the insurance company ensues if things do not.

Scenario #4: Emergency Care in another province/state far from home during
a vacation thanks to a freak snowboarding accident

The Canadian gets transported to the nearest emergency room. She shows
her card. She gets care, she gets better. She goes home.British Columbia’s health bureaucrats bill
Ontario’s health bureaucrats according to an existing inter-provincial agreement.

The American gets transported to
the nearest emergency room. It likely will not be in network. She shows her ID
and does not have to get pre-approved, but needs to call her insurance company
as soon as possible. The co-pays will be higher than if she had gotten
emergency care near home. She gets care. She gets better. She goes home. Significant costs and paperwork will follow if
things go well. A multimonth fight with the insurance company ensues if things
do not.

By the way, the Canadian’s medical records will easily transfer. The
American’s may or may not.

In all four scenarios, both our protagonists receive care. But the American
pays significantly more and goes through more bureaucratic hassles.The Affordable Care Act will greatly increase
access to insurance and care for Americans. It will also considerably
streamline bureaucracy, and limit some out-of-pocket expenses as well. But it
won’t solve the out-of-network problem.

Finally, note that the final improvement doesn’t have to be single-payer
system or free at the point of service (though single-payer is a fine outcome).
We could also end up with more of a Bismarckian system like Germany or France –
where you always owe a small (transparent, sliding scale based on wealth)
co-pay for services.

But
the overall point remains. The ACA is a major step forward for the U.S.
healthcare system, but we will still have a ways to go to improve the consumer experience even when it is phased in completely.